Clinical Documentation Integrity Specialist - Full Time

Are you a healthcare professional with a passion for both clinical documentation improvement and medical coding? Vernon Health is seeking a collaborative and detail-oriented Clinical Documentation Integrity (CDI) Specialist to join our Health Information Management team. This full-time, Monday-Friday position offers a unique opportunity to blend CDI expertise with hands-on coding responsibilities while working alongside providers, coders, nursing staff, case management, and revenue cycle teams to improve documentation quality, coding accuracy, and organizational performance.

In this role, you will review medical records to ensure documentation accurately reflects the severity of illness, risk of mortality, medical necessity, and services provided. You will also support departmental coding operations by assisting coders with inpatient and outpatient coding assignments, coding validation reviews, provider education, and documentation clarification efforts. This hybrid role is ideal for professionals who enjoy both the analytical aspects of coding and the collaborative nature of clinical documentation improvement.

Key Responsibilities

• Conduct concurrent and retrospective clinical documentation reviews to identify opportunities for improved documentation quality.
• Partner with providers to obtain accurate, complete, and compliant documentation through physician queries and education.
• Assist coding team members with inpatient, outpatient, emergency department, surgery, and clinic coding as needed.
• Review coding assignments for accuracy and consistency with clinical documentation and coding guidelines.
• Collaborate with coders, revenue cycle, quality, and clinical departments to optimize reimbursement and regulatory compliance.
• Monitor documentation and coding trends and provide recommendations for process improvement.
• Support education related to ICD-10-CM/PCS, CPT, DRG, APR-DRG, clinical indicators, and documentation best practices.
• Participate in coding audits, CDI initiatives, denial prevention efforts, and quality improvement projects.

Qualifications

• RHIT, RHIA, CCS, CCS-P, CPC, RN, BSN, or equivalent healthcare credential required or preferred.
• Experience in Clinical Documentation Integrity (CDI), health information management, medical coding, nursing, or revenue cycle operations preferred.
• Strong working knowledge of ICD-10-CM/PCS, CPT, DRG, APR-DRG, reimbursement methodologies, and documentation standards.
• Excellent analytical, communication, and critical-thinking skills.
• Experience with electronic health records and healthcare data systems preferred.

Why Join Vernon Health?

At Vernon Health, you'll play an essential role in improving documentation quality, coding accuracy, compliance, reimbursement integrity, and patient care outcomes. We offer a supportive team environment, opportunities for professional growth, and the ability to make a meaningful impact across the organization.